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161-1094-60-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division . INSPECTION REPORT Sanitary Permit No: 556388 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: X Village Township Parcel Tax No: Bardill, Robert & Melissa City Village of North Hudson 161-1094-60-000 CST BM Elev: Insp. BM Elev: BM escriptio Sectionfrown/Range/Map No: z6 b °b /-bo- 6 /v d ~wft e~ 13.29.20.749 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS /,Jib', o.FS ELEV. D/. 3`/ d 2~1 J Septic C7V Benchmark ® t U Do9ipg ~ ~ Alt. BM Aeration !im Holding SUHt Inlet i TANK SETBACK INFORMATION St/Ht Outlet, /4?AJ Qv Z TANK TO P/L WELL BL~li. Vent to Air Intake ROAD et 2& 2 Septic -R=~M 0 ing 5 / > >101 He Aeration Dis Holding _ Bot. System Fin I Grade PUMP/SIPHON INFORMATION Ike / G/1" Z Manufacturer Demand St Cover /o" G, 2 GPM 4 I. / Model Number tIV2 1/ of 5l-) TDH Lift Friction Loss S st Head TDH Ft S S'4_'0' Zle , /02.2 r4 Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM I ' ~2l/U BEDITRENCH Width f Le jth~i No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 5 SETBACK SYSTEM TO P/ BLD WELL LAKE/STREAM MaINFORMATION (LEACHIN HAMBER 0 h Typ Of System: ( I UNIT `~y,~ , . , Model Number: DI IBUTION SYSTEM (O ead anifo Distribution , x Hole Size Ix Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center / Bed/Trench Edges Topsoil Yes g No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ! ! I Inspection #2: Location: 263 Station Circle N Hudson, WI 54016 (SW 1/4 SW 1/4 13 T29N R19W) St. Croix Station Lot 25 Parcel No: 13.29.20.749 1.) Alt BM Description = 2.) Bldg sewer length= ~/,S-n 14 - amount of cover = Plan revision Required? Yes iNo - 2,~ Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. o\ OR& 4 ;C e OF4U N ~M11 RvuVn}~~ Py) S s' fu Q, 1 PSthrt, i ~ ~{hC~ ~ QK~. Imp o~ ~~ti~b~~i ~u ~kv -Ar 3 commerce.wl.g" Safety and Buildings Div n County U 201 W. Washington Ave., P.tx2 i s c o n s i qr Madison, WI 5 3 7 07-7 1 62 Sanitary Permit Number (to be tlied in by Co.) Department of CommR, YS OI~ 5(0 to Transaction Number Sanitar Gent 01lication In accordance with s. Comm. 83.2l(2*t l NYm. Code, submission of this form to the appropriate government*, unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address (i different than mailing address) submitted to the Department of Commerce. Personal inrormation you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1 (m), Slats. S~ 1. Application Information - Please Print All Information Property Owner's Name Parcel # 0 15 J,1 M' 10 _(110_660 Property Owner's Mailing Address Property Location 7q ( ) 5 CO C1 L o rc Govt. Lot Ci State Zip Code Phone Number S W S W 1A Section U hS 0 >v ~f s c ` `l IS o G' $ G T a g N; R ucirclE or one) I1. ype of Building (check all that apply) - Lot # ~~//I or 2 Family Dwelling -!Number of Bedrooms 5 Subdivision Name -0- - Block# CI? S b ) op ❑ Public/Commercial - Describe Use ❑ Ci of _ n CSM Number Village of N V O IC ~A b S 61~ El State Owned -Describe Use ❑ Town of Ill. Type of Permit: (Ch on line Complete line B if applicable) A. ❑ New System -~1Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) LtP v io Permit Nun Issued ~cle B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber ❑ Permit Transfer to New Before Expiration Owner S System/Co monent/Device: Check all that apply) on-Pressurized In-Group El Pressurized In-Ground At-Grade 1] and > 24 in. ofsu'table soil ❑ Mound < 24 in. of suitable soil t ret atment Device (ex ) ❑ Holding Other Dispersal Component (explain y - V. Dis ersaVrreatment Area Information: a Design Flow (gpd) Design Soil Application P>W(gpdst) Dispersal Area Required (st) Dispersal Area Proposed (so System Elevation CQ0 _ S 1 1aao 0o 9S .0o VI. Tank Info Capacity in Total # of Manufacturer y Gallons Gallons Units o ° New Tanks Existing Tanks l ~(g { (p f a. W b: E5 0, Septic or Holding Tank 1 Z 1 I Zoo Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) M3;~t MP/MPRS Number Business Phone Number , ees e~ Ia~a9()s-~~~~ 9oaD Plumber's Address (Street, City, State, Zip Code) 10, ?b P w 13 Lips U V\J) s C, Vlll ount /De artment se Only Approved ❑ Disapproved Permit Fee Date Issued ssuing Age Signal ❑ Owner Given Reason for Denial $ C l IX. Conditions of Approval/Reasons for Disapproval vavx- SYSTEM OWNER: O 1. Septic tank, effluent filter and 5 n/ 3• S `~=~ifJ dispersal cell must be SerV 0d / maintained `f as per management lap provided b I 2. All Set aC requiFe"11f841 *tel*1"trjJ111" m and submit to County only on paper not less than 8 1/1 x I 1 inches i ze as per applicable code/ordinances. SBD-6398 (R. 01/07) Valid thru 01/09 I i K; oc~ CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name. Owner's Address: Ci rCA'e, r Legal Description: s County: ~'rotX Subdivision Name: ~S'I C(Ct, jar S'~ p~' vr~ Lot Number: o? Parcel PD Number: W )09, y- -000 Page 9 Index and title Page 2 Plot Flan F'age 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page g CSM or Plat Attachmehls: Soil Test & House Plans Designer/Plumber: 1I'll) cease Number: 4 y Date: Phone Number 3$L'7w0 Signature Designed pursuant to the In-Ground Soil Absorption Cornponent Manual for POINTS Version 2-0 SE3D-10705-P (N.01/01). Page 1 f t 00 a`'3 S~'rl~lbtJ ~~(tLl~ Ivah~ ~ lQb -cl,~m~orh~ r~~ll Rv,~V~ly g • Fxi s~,+~5 s s~~~-, Poi) D ti1D, bC p I "Oh ~1+C1~ ~~IbK~. IE X3:1 L f ru~~ 0~ nip") eRb~ UKR ccg rJ O 3 i Soil Absorption System Cross Section qSf` ft 4" Schedule 40 Final Grade PVC Vent Pipe q With Vent Cap 1 ~ ..C~b ft Leaching Chamber , by ft System Elevation f 3 ft T ft ft Soil Absorption System Plan View t~ ft 3- L ft Leaching Trench 1 Chambers 4" Dia. Trench 2 Header Vent Or Observation Pipe _ L ` [Trench 3 Lea+china Chamber Sner-ifina ions Manufacturer And Model _ o (-,I -V EISA Rating . a sq ft per chamber Soil Application Rate gpd/sq ft gpd Design Flow + S Soil Application Rate Nob FISA = b_ Chambers bows of chambers each, Page of PL-525 1 laz al k? ~tcz r,~.1~1 Filters P'olylok 1w, of 2 , • ~ ~ is ~ h'saly'tck Inc, 3 Fairfteyd . Siva, wsntanra, CT 06492 Call Trvi Nler+s" F _ e^ 74Imsdr: pcaR+traic,conra _•(dwrre r lt Details i r ErriLUENT FILTER, l i Ralsirt,'g the bar ►n Mar tech oic ^625 EfflUe'n t, Filter ham.', Description ' (Eattat M I ~t Filters F''Olylok, Inc Is P1045ed to add its new commercial filter to ft, existing iins of gi.tanty offivent , Esc nCl $a I.takT^^ fllt~rs. 7"he ILL-525 is rifted for over 10,000 GPD (Gallons Per Days makine it cane of the largest commercial friters in its clasa, !P: has 525 linear feet of filtration slots. Like the R1 r".n ~ Pr lylok PL-122, tale neiv Polyink PL-625 has art at.rt matic shut off ha'ld installed with every { ~ Riser ~~1f~'S filter, Wheel the filter is removers for cleaning, the ball will float up and temporarily shut off istribution Boxes anc i s i;h i'. the syetorn $o the effluent won'i leave the tank. No !1 ~ ^ Tr Y~_~~~^^T~ I 1, ciaiPn! !;I Other fftAr an the market r?an make that I tsPi>? ~?rrlering In`prrrt~atir„Ire P=Ps, basin k, Phttmp (~egGe&t a ouote Related Product$ anal p Symms Saf es, Sanitary Tess Rated for 'i O,Ooo GPD (Gallons Per nay) 13 t°iEltst era > nfarge for q~atafls 628 linear feet of 1/16" filtration Accepts 4' and c3" S~,NCt, ~tO pipe RaktarPaers ~e Built in 0a$ nefleGtnr Automata slurf,,,off mall when filter is rrarnavorl 1 f ndf and ceivera Alarm accessihillty 0 AwePt5 PVC exttsnsion handle I Signs The PL-526 Effluont F"dter shoutd opFrrtft) ofriaisnfly for several years tanner' norrnal Forms 'dpa9 clamps. nnr Imo. A . condlticris ilefore, requiring cleranin4, it is rmeornmendad tllat the filiter be, cia1~ d ev tine the tank is pc,mped or at least even three years . ff tile inarta(ied fllCer GCat1 allied cPWnal,%IsrM, the awnef will be natifred kry ~n alarm when the liter, r p~ed 9ertrlwi 1 n ,,y~~ R AM r1R Sc.ni{cing should be done by a cert(fied septic. tznk punpwr or Ins%jj$r. ng. I +w 'l~a7t Maintenance Instructions, C~rtearek~ A+c~s~~orle~ Preasu m Fi'ttam 7. LO-ate the Outlet of the septic, tank. 2, 'Remove tank cover end pump tank if necessary. 1,10 ~I~t' Ct'~ttrol Product 3, o not rrsQ Plumbing sultprl Miter i3 romOved, Rea P~f t ~ and IkNi~ 4. Pull PI.w525 Out of the housing. 5• Hose Off Hirer over the septic, tank. lUtalcA sUr,a all srslicia fait 484k into s tank. ' Reka¢tr 9ato6, insert the filter cartf^idge track into the housing making sure the filter i5 p prop~r and 1&~ Gt alictrred dno? r,.ompl4tgly in,,srtett. properly 7. Repfeae septic tank cover. PL 5?_5 fn9tatit~iion; f e, waste flows ti to 14,000 Gallons PerDay (GPD). Tachnfoeq S ~µi ila,~t~ii~'~i+ar~ i>r'~•~'kd^tarrti~arl~: ~`~;iati~s, 1. Locats the nutlet of Ghe $e ti . 1~ 1 ecY l~ t Ramous tani< sovtar anp Op flank. PIMP. Filter and Burr 3' Glue the filter hai.lsinq to th'Onp e 4"tor 6"f or. pipe,, If the filter i8 Plot centersd under 4„ x l " Ricer the access awening Lrse a For tore Fr, , i 4. Insert the PL-528 (11ter Info a lice housing. + F)li>aI Adxtm Panel an Y t~ancs i_otc or place of pipe tlP r,Anter filter. J msrt~fitarT~ Ccntroi ! i,ir~c, ,.I,,r~alc r1C717~7°fllirtni Y VIA G I ( Q 167 'f l 'r an i4U1G U 9. 12AM No, 3066 P. 2 Tr ca ~'S CD cn cy Fti ca CCS n 3 t5 .w [ra ti 91 ~ ~n h. ' CA r-~ 'Y- r.. r . a t to 'Llool tares Low SJ ~ ~ ~1r-ery,Y C,4 LU qd- -iln Croix County Plan/Zoning 716.3,36-4686 1/?_ '"'D W~I"$ OWN'ER'S MANUAL, & MA NAt '1 l 1 T PLAN !'age ~ of • FILE )NFO~t~PATid~ld Owner I~Yl6TgIV! 4 0 r~tlx)CA710 ' 8 Permit , Septic Tank Capacity I a 0 0 NA R7ESlts Septic Tank Manufacturer 'r 0 NA PA1ItAIVIfs'i'l~RrS Number of Effluent Filter Me»wf~agturar p ~ L 13 NA i~edrocims Number of public Paaillty Units NA )Affluent Filter Model Q NA l _ t~stirrteted flow (average) ~ ei JS NA Design flow Ipeak), (Estirnatad 1•S) O al/do A Pump Pump Tank Tank Capacity Manufsaturar -fil, 600 ,4( 414 Pump M+anufsatwrar Soll Application fiats .5- 7IA Standard influent/ ffiuanR Quality ugaylfCR Pump Model A Monthly avoregrat Pretreatment Unit Fate, Oil & Grease (FOQJ ego melL 13 Sand/Gravel Filter rJ Peat Filter A 810chem1001 Oxygen Demand (8013,) :9220 mg/1; 0 NA Mechanical ~ C1 C1afnanl rra( faction Aeration p WsCland Total Suspended Solids US$) 1150 m /G, ~ ~,Clther; Pretreated Effluent Quality r Monthly average oloperael Dwell(s) 0100hem➢nal Oxygen !Demand (1300,) !gSo mg/k, 0 NA -a Total Suspended Seeds tTSS) ~~Q m /I, in-Ground (gravity) r] In-Ground (pressurized) Fiscal Collform (geometric mean) ~ cfu/9 00ml NA 13 At-Grade ©Mcttnd 0 Drip•Llns a Other, Maximum Effluent Particle Vxe Yg In d , 0 NA C thar: Ot ar: Cl NA 0 NA C1the3r; 0 NA *Valuas typloal for domestic wastewater and septla tank affluent, Q Q A Other NA MAiIt1TENANCE 9C DULE Strvlas avant service Frra wency inspect condition of tank(s) At least once every, 1'J1erPkP1'li7) ~ ~ ear a) (Maximum 2' years) q NA Pump out contents of tank(s) When combined sludge ,and scum equals one-third (Ya) of tank volume NA Inspect dispersal call(s) marrth(a) once At least 'ovary, 3 a4 s (Ma k-Imum 3 years) 0 NA Clean affluent filter At least once every; ' men (s) r a 4 C] NA lnspaut pump, pump controls aform At least anus every! menr h (s) NA Flush laterals and pressure test At least qn$a every, rnQrl~ht'l;) QtAer; e8r(H NA At laaat once every, C1 sent (s) Other, ears) NA MAINTENANCE INSTRUCTIONS q NA Inspections of tanks ana dispersal calls shall be xnada by an Individual uarrying one of the followine iioensee or certifications. Master Plumber,- Master Plumber Restricted $arn+er, POWT$ Insprotor; l'CwWTS Maintainer; ~'apge ~~rv)ntng Operator, Tank inspeations must include a vleual inspection of the tank(s) to identify any mfes)ng or broken hardware, Identify any creroks or leaks, Mature the volume of combined sludge and scum, and to check for any back up or pending of talfluarlt an the ground surface, The dispersal cell(s) shall be visually inspeatad tQ check the effluent levels In the absarvation pipes avid to check for any pending of 0fluant On the ground surface. The ponding of effluent an the ground surface may Indioats a f+eiiing :onditlon and raquiras the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one-,third (4) or more of the tank volume, the entire contents of the tank shall be removed by a $eptag4 Servicing Operator avid disposed of in 3000rdence with chapter NR 113, Wisconsin Adminlatrativa Cade, All other services, Including but not 11MIted to the servicing of effluent: filters, mechanical or pressurised components, pretreatment units, and any servicing at intervals cf s12 months, shall be performed by a asrt)flad POWTS Ma)ntafner„ A service report shall be provided to the local regulatory authority within 10 days of OOMAISdOn Of any service event, 13MW 14/Qi) Nov-11-2010 10 45 AM St. Croix County Plan/Zoning 715-386-4686 2/2 Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the Infiltrative surface. During power outages pump tanks may fill above normal highwatsr levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Malntalner to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal calls. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soll absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS; ant)blotles; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine, ABANDONMENT When the POWTS falls and/or Is permanently taken out of service the following steps shall lie taken to insure that the system Is properly and safely abandoned In compliance with chapter Comm 83.33, Wisconsin Administrative Code., • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and plts shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another Inert solid material. CONTINGENCY PLAN If the POWTS fella and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system; A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules In effect at that time. 0 A suitable replacement ores is not available due to setback end/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a lest resort to replace the failed POWTS. 0 The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a lest resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the Infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. [ [ WARNING 7 > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name 0LtYh Name - Phone 0a Q Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name P a f►.c Name S G o 20 /i Phone ~ -I' f S Phone This document was drafted In compliance with chapter Comm 83,22(2)(b)(1)(d)&M and 83.54(1), (2) & (8), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~ P- r + t Mailing Address a o ° G E: Property Address (Verification required from Planning & Zoning Department for new construction.) City/State ' / Parcel Identification Number 162 f LEGAL DESCRIPTION cf y J Property Locations ~.J y, , 5 W V4 , Sec. ~ 3 , T __a N R 1U W, Te"o of I V • IUD S o ~ Subdivision S~ a 10~') Lot# . Certified Survey Map # Volume Page # Warranty Deed # Volume 7 Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER FR•rr, CATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three the system can affect the function of the s tic years or sooner, if needed, by a licensed pumper. What you put into responsibilities are specified in §Comm. 83.52(1 tank as a in Chapter 12 - St Croix County Sani 1 system Owner maintenance tY tart' Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification fo owner and by a master plumber, journeyman plumber, restricted plumber or a licensed r veri signed by the wastewater disposal system is in proper opera P~Pe Eying that (1) the on-site ting less than 1/3 full of sludge. condition and/or (2) alter inspection and pumping (if necessary), the septic tank is Uwe, the undersigned have read tsntents and agree to maintain the private sews e standards set forth, herein, as set by the g disposal, system with the Certification stating that your septic system has a and the Department of Natural Resources, Stilts of Wisconsin. Zoning'Department within 30 days of the three fined must be completed and returned to the St. Croix County Planning & _ lion data Uwe certify that all statements on this his f property described above, by virtue of a warranty to the best of my/our knowledge. I/we am/are the owner(s) of the tdeed recorded in Register of Deeds Office. Numbi7 of bedrooms SIGNATURE OF APPLICANT(S) I_L_ a ~ DATE `'"*Any information that is misrepresented ma Y w the sanitary permit being revoked by the Planning 8c Zoning Department. Include with this application a recorded ~y reference is made in the warranty deed. warranty the Register of Deeds Office and a copy of the certified survey map if (REV. 08105) 3T elt.t" E BAIL OF vs' ,raoa.i3n.~szr r.-s0- QC]GU [vtElV E asXAX`•IS WISCONSIN . a Yr,a, r> nCC .vm- 60't aacflrmle(rs IIArJC z .-i~g.... JVARRANTY DEED !r - F pN { f!~ fA~~ V f tr it. made between . ~~nl a.~ L?? 3~a2? a ~lcla ST. CR4)IX M WMs u Larson, .t + az'd. ftx Record fl* 26t.h C!_V C4 2 61 Gccrte r - - ~t t' wife as surviors'1ip >~ital propzrty - - - - 1 Grantee, Ej»TIeSSeth, Thar. the srid Grantor, for a valuable consideration 11 G 4~ RCTURt, T4 t County,. Sthtc of Wlseonsin. { _)r 'Tax Parcel No: ~t Lot 25, St Croix Station in the Village of North Hudson, St. Croix If f'i~ilntvs 11r;Cnn-:-In °ll (S SEW u This iS__rlQt............ homestead property. (is) (is not) 11 Together with all and singular the heteditanwnts and appurtanunces thereunto belonghig; Anti (;r.eut;.Q;r........ - warrants that the title is good, Indefeasible In fee. warrants simple and free and clear eI' encum!)raaces except ! i easer_lents, restrintIonz arnsi .ri vhi g f-yfawr of Tzannrd, if any and willwarrant and defend the same. Dated this 19_MI. day of r73T'Ch... 1R ? It Q (SEAL) ...\`3 Qk '~'1ar"e > T.+ne~r n.'rr .,,.a I) A E. G. Larson laI ; , '0kSEA' - AUTHENTICATION ACRN 0 ME DGT)riI3PIT 8ianature(a) STATE OF W1SCOXSINI 11 St - . . authenticated this day .,f--------------- - ' p.,rserally -n-re before me •t),ia dny of t>~, It , the above named f--------------------------:-------------------------- TITLE: MEMBER STATE BAR OF Wi3Cu_:z-iN7 • I1 (if not i _ i l! authorized by § 70(S-0E, V;:s. S :.s.) to oie known to be the person who executed the ll forez-ing insfrunient __,d ack fhr_ _egns n; tl 3HIS IN--^rTRUM1IENT WAS nRa.F:Fn ny ^ T Kristina Oglard Umdeer ierr' v 1 m'f . (Signaturv_s tiny lie all 011 1' ri.iir V . Croix Co . t , a. it - r Ic .I:: f iP 2s -7.) ' .erg . ~ Wisconsin Department of Comm SOIL EVALUATIONRT 2303 Page 1 of 3 JqC1 Division of Safety and Buildings 5 loi rdance with Comm 85, Wis. Adm. A.C.E. Soil & Site Evaluations County Attach complete site plan on P(; L11!! 1 L not less than 8%x 11 inches in size. Plan must St. Croix include, but not limited to: vertical, horizo R point (BM), direction and Lei percent slope, scale or dime .1 `d location and distance to nearest road. Parcel I.D. r LW" -1094-60-000 -7 1 Please print all information. Reviewed B Da e . Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Bob & Melissa Bardill Govt Lot SW 1/4 SW 1/4 S 13 T 29 N R 20 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 263 Station Circle North 25 na St. Croix Station City State Zip Code Phone Number City e Village J Town Nearest Road Hudson WI 54016 (715) 386-8686 North Hudson Station Cirde North I New Construction Use: yf Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD N Replacement Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable na General comments and recommendations: Site suitable for cone na OWTS dispersal cell with 0.5 gpd/sq.ft./day loading rate. Recommended trench elevations to 93.00'. - Boring # I Boring Pit Ground Surface elev. 96.57 ft. Depth to limiting factor >90" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 1Oyr3/2 none sit fill na na na 2fm1c 0.0 0.0 2 12-24 1Oyr3/3 none fsl 2msbk dsh cw 2fmc 0.4 0.8 3 24-36 7.5yr4/4 none Ifs & gr 0 sg dl cs 2vf,fm 0.5 1.0 4 36-63 7.5yr4/6 none Is & gr 0 sg dl cs 2fm 0.7 1.6 5 63-90 1 Oyr4/6 none s & gr 0 sg dl - - 0.7 1.6 Horizons #3, 4, & 5 contain approx. 30 - 40% gravel & cobble. F-il Boring # _j Boring N Pit Ground Surface elev. 97.53 ft. Depth to limiting factor >102" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 1Oyr3/2 none sit 2fsbk mvfr as 2fmc 0.6 0.8 2 7-21 1Oyr3/3 none Its Osg ml cs 2f,1mc 0.5 1.0 3 21-51 1 Oyr3/6 none Ifs Osg dl cs 1 fnn 0. 1.0 4 51-62 1Oyr4/6 none s 0 sg dl cs lfm 0.7 1.6 5 62-72 7.5yr4/6 none Ifs 0 sg dl cs - 0.5 1.0 6 72-102 1Oyr5/6 none s Osg dl - - 0.7 1.6 * Effluent #1 = BODS> 30 < 220 mg/L a TSS >30 150 mg/l * Effl nt #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signa re: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 9/27/2012 715-248-7767 2303 ~ of 3 PROPERTY OWNER: Bob & Melissa Bardill SOIL AND SITE EVALUATION Page PARCEL I.D.# 161-1094-60-000 A.C.E. Soil & Site Evaluations REPORT MEMO See Fogerty Soil evaluation completed for original system installation dated 7/28/87 & Ulbricht soil evaluation for Terra Lift system rejuvination dated 9/20/96 for further soil information. • /o Ctc{,c d /Orcp, ~ 6oe 2 • ~ ~/Q !/Q /CtQ,~%OYl ,(fir--L~~ A E/td4r~on Z:zq -jr-- L`'J~i3fin9 ScCu.r^r{~Fcyrc~ 4(, l-3 a3 /{u.~.sorJ, ~.v/. s3rvi6 a~ SC;F~' sw%y kvy~ So c zs, / lea. to/-~oyf~ 60' 00 t: Ey/3fq~ d,'~ ~pP~'~c" /oca F:rv~ r Gcd( .#/8rt/T. of uxr~l6n bc/r~ ~elAdl i Eri3~i~q ,ZcO o►Q I EQSGYIH7'~ ~ +r ~ l ! of'asp ~ h` iE ~ 2 98.sa \ J lI e ~ p~ c EXi:s~F:.~g 5/ 6edrov~ ` K d ~eSidegCC ~s 'C ~ ~ ` bar Yd ~ ~ G/tc.f✓'rC. 1 1 I ~ woodeG/ L°Jrk3~j. " /o ccc ,,c(,,Org/o. 5-6,tee ~7i/ 2 !!Q ~Gc 2L%On ~J~ • p~SSr b~P 5 yS~s,-, 1 ~ y0~. • Sa,/e✓~,/u~y., b Fp J e eFiy~ S,-CIO O s /5 SCGcU/e / ~c 03 G., gc,60 w< O Lof.ZS"/J/Q o"eji-I• '~•it oil ZS, wooded !J///a .cQf /j6r ls~~ Btu SI( k Cr~r r ~l, 4,6 J1~ •~s f . -it r 90. Cw,; -EG✓ ' - :zo ^^-y, J \ i Esasedr~rr,4 OPay C Eie~ ilk I ~ ~ ~ ` ucct7•%c. ~ ~ Kt-s^r'+Y45 1 6ru~tiy I Pe,, 3 c,~ 3 N i° 26' E/ m W D W 209.90' Ln n O I • / / N 1° 26' E N 1.26' E cn •2 / 1930250.00' 150.00' 02 1 ' - ti Jo. v e-s S N Al 3. 1 2 1+v /6 /i .41 cl (71 nZCn i~ gN o~ - o'er / 0 T. = (A / ~w 00 NI.26'E I I '.n Z z m 200.00' a' = «a' N I° 26-E :D ao r I r I 200.00' W Z t 20• ~ •y/ 3S' N) 66i I StOe~ p >0 8 @ I N 0 N O >N Q W 4~ (7) N I I I O m 31 O N f+1 U~ " 33' I-4 v 1 0 O p D z u N1.26E I co w I HIV :q -4 ca 200.00' 1 O ' I N 1. 26' E a• 2,~ I i// A Co 0 1 0 o 1 ' 2 0 0.00' { °?e I /6 _walwaCE N 10 26'E 30• `'►t~ 118.0"1' 102033'30' V 2 15' i l3 m N Q~ N W N 1°26'E -1 - N tT> i r:a sv' E~JEMENT r- 2 255.00 Q (No ^ o ~ a _ 200.00' o;.1 51 - N Q m A~ W I W N Q upN~W ~I•2 6' E a WZW to z: 1 A I N I\J N W m 1 N 1-26'E 255 o I m' m I O ~ U) - a oA 154045 ~ Z03*83. I 1 0 m m O m 6 , I o w 11 N 1.26' E I t o (a (A i I f °-200.00' I N to 2£' E w O V c I :0 I 200.00' o nQ) m (A g I I N N / 3o3\F Ct C, r ,Pr 1'1:A } ae 13'x• ,e 0w N1.26'E 162.34'3! ~_a~~•~6C O. lA'ILA 200 40' , ►y r Ii 1`' / ,`yy I t x ,.A • ZM tS ~ ~ r ~ ~ t~ ~r t ~ , i. i ~ ~ ~ ~ ` , w 4r 9~ b / ~ts~:M as I 1(fj ! ~i 1 ~~Er. ^ r~ r Ir ~ ; _ 1 ~r t~ ~,fj, a ~ ,~0~ ~ ,a~. ~ 1{~^ Z'1a' y~ t t ' I ~ N ~ : ( ~ ~ ~1 ' • ~.r ~ p~l• r - ~ •a i 4 iti Zi N I Ell r 1 ;JPy it O° S N / I A } "J~'Itt,°` N i; 1"'3'.c.r A t., iO •1'i: 6 / \ 4i a N O \ r` 41 \ n a= ' ,T3.3 /a ✓.3 ~i• ~s j. { , ' it a . , ~ s~,• 4e• • .~i ,r, oo fir, ~i'i A ~~e ~ 4 l ` s'` 88.31' u~ .s % N ON, r.\6\ 0, - 368.6 48' 9~J vi Is* i88viW 345 ' fobo`r/~ cvMN26'E A ~i 1s` ` 0~-~ji N8°rW 32 ut 0) r/ ~ ~4 ~ N D• w +$C ~ f OD N 6 a v / N 33' A N to O 400 Ilk N tj 69 I 25QOU 343.43 V VILLAGE S 0018'30'W 12®T.oo' ti K N UNPLATTED LANDS of, n A Tv °Dt'<a v O O ~ 0 3 °0 3 o I c O 69. p e» ao 00 0. ° 0 c I I o I I I 0 N C N a N (6 h (D c I w I E I Q n (n co 4) L rn Z v z° v ° c {L c U. C N O 0 3 € 3 CL aim I 3 C ° Z rn~ Y O I w; p Z y y `m M N LL LO LL co N fA O O Z c c o .O a~i Z 2 aci Z v) F c ~ I c ~ ~ O c m a~ C aNi y a~'i a~ o L WV (L ~ CL i O N O O N Q 0 O Z m z Z co Z N Z c c I Z.; ~ I R E N m 0 m co (D CL « c CD D D a °a o D D a n m ~2Up C\l c°~ co N U) = Q1 U) <A 7 O 4= N N ~ v - Fy Fy f/1 N j a LL Z O C. • co a a a o a a a a iv I ~ I t~ J U = co rn = °O' Z a1 Z z r' m O a C) *~l U O U N N O O N N O w U 0 0 U r _ ( N N c ml c m a c in N~ c io d Q} v) i ~a v d ¢ Z in io ~ I Cr 7 M y w M ai a O = N N C N N C O E 0 'a ~Y O 0 V d C 4) CD :3 V a O O O N O N C C w p "O N N N Ul) tq N yVVV- t~ C p C. O C y y° d N N C ° aNi rn w y Z z v m c in i.. N m v p C E E ° v p r'n o c0 v • m 0) O Z I.O H CO co O Z Z z 'L'am CA O 4 a: r v~ € a € a L: u (L C a rr`Iw~i ` 'c 0U)(J ~1 A 0IL2 0aico Form- S T C - 104 t 1 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP7a/11 ')r A"AWW SEC. T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION Sf fb LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IlHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM z~ N< yJ > -J 3,f y ~s I 3s ~!t /id X s~ INDICATE NORTH ARROW PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: oa f l,~a~fr ~i2, 9 ~ro~ X96. 7 Width: /5 Length: 117 Number of Lines: 3 Area Built: ,PY6 Fill depth to top of pipe: lill Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft Number of feet from well: ? so Number of feet from building: _~S (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box 0 been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: •'ARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMjV RELATIONS SAFETY & BUILDINGS ARQ:s...kgp m o PRIVATE SEWAGE SYSTEMS DIVISION MAQ*1SON, WS 53707 BUREAU OF PLUMBING Lot 25 St. Croix Station CONVENTIONAL ❑ALTERNATIVE State Plan LD. Number: Village of North Hudson ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound utassignaal NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Robert Bardill 715 Lund Street NOrth, Hudson, WI 54016 BENCH MARK .Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: JCST REF. PT. ELEV.: Name of Plumber. MP/MPRSW No.: County: Sanitary Permit Number: Dave Fogerty 3289 St. Croix 99026 SEPTIC TANK/HOLDING TANK: MANUFACTUR ER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER ♦ 1 Ayo J, L~ Q3 ,7 PROVIDED: PROVIDED: BEDDING: VENTDIA.: V VENTMATL.. HIGH WATER I v / YES ❑NQ ❑YES NO ALARM NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH YES LINE./~ I AIR INLET. ❑ NO FEET FROM C I ❑YES NO NEAREST 3(~ DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER ❑YES ❑NO PROVIDED: PROVIDED: GALLONS PER CYCLE: PUMPANOCONrROLSOPERATIONAL: ❑YES ❑NO ❑YES ❑NO (DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL BUILDING JVENTTOFRESH FEET FROM LINE. AIR INLET. PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: L. I BED/TRENCH WIDTH LENGTH NO.OF DISTR PIPE SPACING COVER ^ TRENCHES. INSIDE CIA #PITS: LIQUID DIMENSIONS fV~ / MAT IAL, PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. BELOW PIPES ABOVE COVER: ELEV. INLET ELEV END: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH q n ~j PIPESr~ FEET FROM LINE:q , / ~ AISIILET S / 5'C¢0 l Z ( } NEAREST--i► o(7 -~S S MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑YES ❑ NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER rexruRE PERMANENT MARKERS. OBSERVATION WELLS. DEPTH OVER TRENC H/BED DEPTH OVER TRENCH/BED ❑YES ❑NO ❑YES ❑NQ CENTER. EDGES: DEPTH OF TOPSOIL. SODDED SEEDED. IMULCHED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. TRENCHES: FILL DEPTH ABOVE COVER: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBU TION PIPE MATERIAL & MARKING. ELEVATION AND ELEV.: ELEV.. DIA.. ELEV.: PIPES. DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO ❑YES ❑NO COMMENTS; PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑No NEAREST Sketch System on Reverse Side. in in county file for audit. SIGNATUR Ef` TITLE: DILHR SBD 6710 (R. 01/82) f ✓ Zonin Adm' LqtLa or SANITARY PERMIT APPLICATION COUNTY _ Rol Si.C ( ®`LHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8'/s x 11 inches in size. application. PETITION -See reverse side for instructions for completing this FOR VARIANCE F-1 YES No I, APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATIOON ERTY LOCATION E (or) W PROPERTY OWNER t/4 1/a, S T ' N' R ation Robert Bardill LOT NUMBER BLOCK NUMBER St. CroiNAME PROPERTY OWNER'S MAILING ADDRESS 25 715 Lurid • N. CITY NEAREST ROAD, St ZIP CODE PHONE NUMBER VLLAGE N H[JDSON Station Circle Drive N. CITY, STATE 54016 386 5888 Hudson, WI II. TYPE OF BUILDING OR USE SERVED:X OR ❑ Public (Specify): Number of Bedrooms if 1 or 2 Family 7 applicable) III. PURPOSE OF APPLICATION: (Check only one in ~ Check # 2, 3 or 4, if e❑ Repair of an El Replacement of d. [1 Reconnection of Existing System 1 a 0 New b. [I Replacement c• Septic Tank Only an Existing System System System Date Issued 2. ❑ A Sanitary Permit was previously issued. Permit reement to County Copy. 3, El Existing System has been than one owner/build'ing Attach Common Ownership Ag 4, ❑Th The System is shared by more than IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) ❑ Experimental 1. a. Conventional b. [I Alternative c e- E] Mound f. ❑ IGP 2. a. ❑ System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ® See a e Bed b. ❑ See pa e Trench C. ❑ See a e Pit PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOS8E20(Square Feet): 95.gr Feet Private El Joint [I Public 2. © 5 820 CAPACITY Site Fiber Exper. Prefab. Con- Steel - plastic App VI. TANK in allo Total # of Manufacturer's Name Concrete structed glass INFORMATION New xts sting Gallons Tanks Tanks Tanks WEEKS CONCRETE ❑ ❑ ❑ Se tic Tank or Holdin Tank 200 ncne 1 200 1 ❑ Lift Pum Tank/Si hon Chamber VII. RESPONSIBILITY STATEMENT tans. I, the undersigned, assume responsibility for installation 3 thNo Stamp )ewage system shown on the Nattache p Business Phone Number: tt Plumber gnature 749 3656 Plumber's Name (Print): ert Name of Designer: Plumber's Ad ress ( treet, City, State, Zip Code): D. of D Fogerty ert Hats. Rd. Roberts, WI 54023 csT# VIII. SOIL TEST INFORMATION 3233 Certified Soil Tester (CST) Name Phone Number: Dave Fogerty 749 3656 CST's ADDRESS (Street, City, State, Zip Code) WI 54023 ts. Rd. Roberts, Groundwater ate Issuing Agent Signature (No Stamps) IX. COUNTY/DEPARTMENT USE ON Sanitary Permit Fee charge Fee ❑ Disapproved g7 C- Approved ❑ Owner Given Initial ~'a O O a~ 7 Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: ICtV\ r~ e d,42 ACA bt:~ -T~0,i,,C_0 0_ ~e f~ v SBD-6398 (formerly Plb-67) (R. 03186) DISTRIBUTION: Original to county, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY APPLICATION PERMIT TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal an criteria in the Wisconsin Administrative Code will be applicable; new 3. All revisions to this permit must be approve by the permit issuing authority. A new permit may any if there is a change in your building plans, system location, estimated wastewater flow numb be needed rooms, etc.) , depth of system, or type of system; 4. Changes in ownership or lumber re uire ( r of bed- submitted to the counp p q s a Sanitary Permit Transfer/Renewal Form (SBD ; ;gg) to be y prior to installation; 5. Private sewage systems must be properly mraintained. The septic tank(s) should be pumped t, a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concernin State of Wisconsin, Bureau of Plgumbirng r608 266-3g sewage syster:?, contact your kcal code acfrnir i ;trator cr the To be complete and accurate this sanitary permit application must include: 1. Property owner;; nac,;e installed; and mailing address Provide the legal description whey the system is to be ll. Type of building or use served: If public is checked, indicate type of use (i.e. 10 knit apartment 30 III. Purpose rant, etc.). of applicatrilonin numer of : Check onlybedrooms seat in if building ; Complete rs2 if ne or two family dwelling repair; # permit is for tank replacement, r= IV. Type of system: check all appropriate connection or boxes depending on system type. Check experimental only if project Wisconsin; is in conjunction with University of V. Absorption system information: Provide all information requested in ##1-6; Vl. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank materiel. Complete for a// septic, lift/siphon chamber and holding tanks for this system. Check experimental a nstaf tanks received experimental product a VII. Responsibility statement: Installin Pproval from DILHR; approval only if g plumber is to fill in name, license number with a MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; appropriate prefix (e.g. VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8Y2 x 11 inches must be submitted to the cc wit y. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. pump GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiaticn and public debate. The groundwater bill included the creation of surcharges Groundw .ater can effect ees) for a number of regulated practices which ~ gro unc+wat_r. The surcharge took effect on July 1, 1984 All of the water that Vvtsco is used in your building is returned tc fir;,s g r_ the groundwater through your soil absorption buried a~, it e system or the disposal site used by your holding tank pumper. t The nor ~es c:aliected through these surcharges are credited t, tereo by the Department of Natural R_sources. the groundwater f sd ;xdr,inis_ { eater, gr_)ur?dwater contamination in~ estigationshand establishm` nt of st ndardsr Uround.; it's worth protecting SBD. Ntt i~x -6398 (R.03/86) 3iF'', APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property 6 2S -(1 1k ~ - . - . I - Location of Property ,p+ --_i:Z.~L~► S"-'re I& , T U' Nie v~ loo Township G,~` ~j►0 Hailing Address jy- 4--A,_ yI Lt/~ s s" 4o-ldl,(~ Address of Site ~r,,v Subdivision Name .S C.f'O % k Lot Number Previous Owner of Property , c a ~*svh Total Size of Parcel l~ ~Q ~G11rd ZZ-4 V Z--a G Date Parcel was Created Z6 1 /Feji7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No volume 7_ Z. . and Page Number Jr74 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and cage number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION R.~...."M'rNNN~` # .9"es ~ 't - «......*ial........,. p•. , . Wk 2%A do td...... ............................y .IIeaNA~1p. / Qromw, f0! ~ fvt~{t ~ ii fi $MOM M YN w*w tltt ld wA ft dwell! "d Mitts IH ( ~ I1. M~I~ of wieumm: 3r tom; _ was `.Croisnation 311 tin r s OM!'it a, 1{!1sooelasr,. ~ t 14 V WANSM "IgdbW w" tM "d et Itr trt kOMMtttAet s MW t{purtotttu, thasomb YN ss ' ' 4mucl .ed fm :nr eM.r ~t riera~le j and ru twvr-Nay of r amd, it #Ew e V mulma aid Admd as tin. 1' Mrt . .,1,I dap of Ih r (8EAL) ~ I ~~:-.+r+ • ...Q~1']~8.8..~A1• , E. 0. IsImm !~4r 4t1JIBUTIOATION A©iNOwi wp! ` ' ~N..»»N.............» STATS O! wIlO *ww t. lbrncwnmmy come heft" a", { NN_ . gf*ftB" OF ` wIt00N81N ,,,.........,......................rw~, . H H a STC - 105 r' r a SEPTIC TANK MAINTENANCE AGREEMENT ry+ St. Croix County z ` d OWNER/BUYER I ~ Nk: ROUTE/BOX NUMBER64-actC.! A/. Fire Number .CITY/STATE ZIP s"~La`d S~; Gotilc ssi'C1/0' T/a v3 PROPERTY LOCATION: ka+ es k, Section , T _N, R _W, Town of y!•~[cSe~ -f-P. #kpg, St. Croix County, Subdivision csf"C-rv"', Lot number RJ^ . Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. . U'00/ SIGNED f44c'` y "U'000' DATE Z P- St. Croix County Zoning Office P.O. Box 98:* Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. VDUS T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DUSTRY, DIVISION LABOR P.O. BOX HUMAN NDATIONS PERCOLATION TESTS (115) MADISON W 53969 , 707 (H63.090) & Chapter 145.045) LOCATION: SECTION: MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: COUNTY:: OWNER'S/ObIN Eft"3-NAME: MAILING ADDRESS: USE DA S OBSERVATI S MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTION R A ION TESTS: OResidence ~ew ❑Replace S: ' 4 ,p 7 RATING: S= Site suitable for system U= Site unsuitable for system O CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: ptional) ps DU Os ❑U IS ❑U IE]S ❑U ❑ S DU do, If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: 1Z Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- L ~Fl" 5- > 0 n . ~i Ar / r n w 0 B- 7 (7 6. ~6 6 -1 9 D mS r m 4J Co6 B- F0 fi 8 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD 3 PER INCH P- 3 0 2 %c ~1 P- P- 3 2 /U r e P-_ P- 30 s ' s ? r s P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9s. 9o 1 ~ j r I i _ _I I 'TN E { f j ~f i t n I Ed i I - I E i I ~ i 7 INSTRUCTION FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for w,iting profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separat^ sleet may be used if desired; 8. Make s, your benchmark and vertical elevation, reference point are clearly shown, and are permanent; 9. cot appropriate boxes as to dates, names, addresses, flood plain data, percolatior. test exemp- xior , if t: , 10. If t i h as flood plain,:-r- ion) does not apply, place N.A. in the appropriate box; 11. Sign.:.. e your current di d your certification number; 12. Make I I- ind distribute as r~~.aired. ALL SOIL TESTS MUST BE FILED VJ1ITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS rtes and Textures Other Symbols - Stone (over 10") BR - Bedrock cot) Cobble (3 - 10") SS - Sandstone gr - Grave! (under 3") LS - Limestone - Sand HGW - H'• h Grormdwater Coarse Sand Perc P, elation Rate r. Medium Sand W 11, - Fine Sand Bide; 'ling Is - Loarny Sand j - G :ter Than ' sl - Sandy Loam < - L, ;s Than *1 Loam Bn - B It *st`I Silt Loarn BI B si - Silt Gy - Gr 1~cl - Cl Loan) y - y " vV scl - S tg. !Flay Loam R - R I sicl - C V Loam mot M sc lay w - VIJ sic - fff few, `c CC cc Pt n ni M .ny rn - d - di _ p - pros- HWL - H r _ r x € - ~ sun{cC- BM - Bench M. , VRP Vertical F ':rence Point Jr, ~ 1 w w I ~ v ~ o - b I v A 6 I ~ ~ 1'i V ~ 4 w ~ _1 h r~ J~ 4 ~ 6 y , W cl, ,Ilk h ipA ya i - i z~ i s y ~ ~ T ~ W o u v N y V v e ~ I C i W All 1 0 ~ I 0 1 rn V~ ~ - ~ 7 I y - r- j ~ e 3 ih v (A - -wa w Cli 1 , ~ 4 1-_ e I, ti'IiS t ~ i f r i i h 1-40 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations Safety and Buildings Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284160 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: BARDILL, ROBERT NORTH HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANKTO P/L WELL BLDG. A irito ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift I Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 N DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: NORTH HUDSON.13.29.20W, SW, SW, LOT 25, HIGHWAY 35 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. f f ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION BureaSafetyu of and Bildi uildiinnggWaterlSystems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. 5k . C, (G~-\ • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs` ❑ Chec evl Ion to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pro ert y Owner Name roperty Location 1/4 1/4, S T 'Zcy, N, R (orcg? Property Owner's M fling Address Lot N r Block Number A• r.l C. it;v, State Zip Code Phone Number Subdivision Name or CSM Number ( L II. TYPE F BUILDING: (check one) ❑ State Own ❑ ity Nearest Road Villaoe Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 1 i w 3 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo {6~ 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New ----2.-❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. 1st Repair of an ------System System Tank Only Existing System Existin System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued - V TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 1 10eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Feet Feet VII. TANK Capacity INFORMATION in gallons Total # of Prefab. Site Fiber- Ex per- Gallons Tanks Manufacturer's Name Con- Steel glass Plastic App- -New p` Existin Concrete structed Tanks Tanks Septic Tank or Holding Tank - ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber El ❑ 11 Q Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. ~s Name: (Print) rd's Signature: (No Stamps) Po4FlANgPR6k*Pd..: Business Phone Number: ~ Z. rc)or /S-3t:23~ 30 Address (Street, City, State, Code): ^ } IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa ry Permit Fee (Includes Groundwater Date Issue Issuing Agent Signat (N tamps) Surcharge Fee). pproved ❑ Owner Given Initial Adverse Determination l X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is vaI id for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. IMP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: U :11k~-~ Section T Z=f No, R 41 1 , .q W, n of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: Did flow ck occur from absorption system? Yes Y, . No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer: (If known): Age of Tank (If known): (Signature) (Name) Please pri t cu ~C" t -1 ppp (Title) (License Number) 101 --1 D I(iL Datd Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP/MPRS t Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP17alkI p SEC. T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISIONf b LOT 2,e- LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•-LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~y,off - --J y5 i QE~ /f O ~~-4, 3,I y L~ r , ~S 3S I i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ice. 'o PUMP CHAMBER ; Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: /,t a fir, 9 ~ 9r. 9 Width: /S Length: / Number of Lines: .3 Area Built.: X5'6 Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,O Ft. Number of feet from well: > Soy Number of feet from building: `S (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: rc Wisconsin Department of Industry, SOIL AND SITE EVALUATION J Labor and Human Relations Page ` of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and s G/~ 'l percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location q ~R o.BE?~ I fSA IRL)l L L Govt. Lot Al 1/4 A/>1/4,S 13 T 2! N,R Z~ E (or o Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# ST 1i O/A 5 rf -T )OAJ City State Zip Code Phone Number Nearest Road tf UGZtoJ (JI. Stja/(o (7i5 > 3~~461 & ❑ C1o Village sown f~fffiou '6~ez , ❑ New Construction Use: E Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial- Describe: Code derived daily flow .1 I gpd f _ ' r Recommended design loading rate. 7 bed, gpditt trench, gpd/fit Absorption area required .257 bed, ft2 7 61 trench, It 2 p Maximum design loading rate ~ bed, gpd/fl2 ' D trench, gpd/ft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable Nf It S = Suitable for system Conv~tional Mound in-Ground Pressure AT-Gr a System i ill Holding Tank U = Unsuitable for system s ❑ U C~ s 2 U C'g ❑ U~D< 1:1 ~U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots GPD/ft2 Gr. Sz. Sh. Bed Trench M*V&l/y A// SL Li C s / f MT IAA N P f'S TU e i3 Ground Z 15' 3 /0 3 Z5 /e S CS -Lf $ (v Y 2-- ft. -/0 7• D ~QQ- ~ ~ . 7 Depth to W 0-1. limiting factor In. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. 'ik ?-ILRP.(6-k-T- -7)5 --3,F6 -('lf-S Address / \ n r. _ rlafa CJ~ ~ per sr.....r.__ PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL 1.1014 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground ; elev. ft. ' Depth to limiting factor in. ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G D/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor In. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) T - n C)r fl o e, - t t ' O ^ t O (A F*s 0 l~ - X o ~ N N _ - V N C~ ~ ~ p oo I ~ o Cn I J I N IZ) I ~ I w I ~ I y I ~ N STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ' t ^ "4- • ) 1 MAILING ADDRESS (0 3 p N C G Cc-, C/_ PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATES rv ~_Q . PROPERTY LOCATION 1/4, 1/4, Section T Z 9 N-R Z~ W '1 OF ST. CROIX COUNTY, WI SUBDIVISION L IQ LOT NUMBER CERTIFIED SURVEY MAP , VOLUME-7 _7_Z,.PAGE 5 7Z; LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year ex ' tion date. SIGNED: DATE: G~ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. owner of property 7? .1 c .fi `\L> G d & ; ; Location of property 1/4 1/4 , Section 1 3 , T I C4 N-R -ZAj W Mailing address Address of site Subdivision name Ste. Ls~ ~E~..~cz•.r Lot no. Other homes on property? Yes _No Previous owner of property_ Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes _)~__No Volume =land Page Number as recorded with the Register of Deeds.. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner (s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. igna re o Ap icant Co-Applicant ASiq Date at re Date of Signature ('.t 1-5982 :1~ T" BPAc[ PE':[RYt~ ►OR a[CORDiNa DATA • STATE BAR OF NI~CONSIN FOft i DocOMENT NO- WAnSANT1 VEET) II .H- "4 P~,t572 'i WG!$TER5 0FHCE 4► 01S li ST. CRO(X Co.. WISE _ _4 Clrles _ 11~ f3 pfeW made between 1'd. for Recfl d 26th day 0f_ 0.19 87 Larson I'. . QS • Grantor, I' 8:30 A Nfeliss$..Bardll,. Ypsbaxtid..$..... ............................11 and........l.P.~.. , 1avbErt C:..B a .q rty..........-•-......--••...._. 1I and. wife as surviorshii ireritk~.... I Grantee, ••.--.-.-valuable consideration...... W-tnesseth, That the said Grantor, or a I acTUnN TO inc........ St (Shan or • described real estate in Conveys to Grantee the following County, Stale of Wisconsin : Ta: Parcel No* St. Croix Station in the Village of ti3rth Hudson, St. Croix Ipt 25 Co mty: W_Jsconsin. S S tie homestead property. This - ~SjT'-Qt--- is (is not) appurtenances thereunto belunbiu8+ Together With all and singular the hereditaments an ood, defeasible in fee simple and free and clear of encumbrances excepi in And------ the to 1, of record, if anY • Warrants that the tale 6 t s= Cfy easements, restrictions and righ and Will warrant and defend the same. of Defied this (SEAL) ~ ~ J ~ -la ; a r,s' . Chax' ' to • 1•- E E(3 Larson - . j s (SEAL) %Yl/ y f Z J~ i • •-•-----ACSNOWL$DpMEN AUTHENTICATION STATE OF WISCONSIN s& suture(s) GrOix county. day of r - . Personalty came before me &j-_.•__ 19_.---- h 19__-----• the above nam authenticated this --------day of N13r'c••.......... I o ailes..E._.. n•._.... - TITLE: MEMBER STATE BAR OF WISCONSIN erson Who executed the to me kno~~'n to be the p .r~ .~t_ - __a ..,.t:.,-tiid"~lae the san